Inspection on 27/06/07 for Dudwell St Mary Care Home

This inspection was carried out on 27th June 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Dudwell St Mary Care Home 27/06/08

Dudwell St Mary Care Home 07/12/06

Similar services:

Springfield House

Sutton Lodge Nursing Home

The Shelley

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Dudwell St Mary New Building Etchingham Road Burwash East Sussex TN19 7BE Lead Inspector Debbie Calveley Key Unannounced Inspection 27th June 2007 09:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Dudwell St Mary New Building DS0000067584.V339044.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Dudwell St Mary New Building DS0000067584.V339044.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Dudwell St Mary New Building Address Etchingham Road Burwash East Sussex TN19 7BE Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01435 883688 01435 883037 dudwell@barchester.com www.barchester.com/oulton Barchester Healthcare Homes Limited Vacant Care Home 43 Category(ies) of Dementia - over 65 years of age (30), Old age, registration, with number not falling within any other category (13) of places Dudwell St Mary New Building DS0000067584.V339044.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. The maximum number of service users to be accommodated is fortythree (43). Service users must be older people aged sixty-five (65) years or over on admission. The service provides general nursing care to thirteen (13) older people over the age of sixty-five (65), accommodated on the ground floor. Thirty (30) service users with a dementia type illness only to be accommodated on the first and second floors of the building. 27 November 2006 Date of last inspection Brief Description of the Service: Dudwell St Mary’s (New build) was registered with the Commission for Social Care inspection in May 2006 as a care home with nursing. The home was purpose built and is presented across three floors, with level access to all floors. It is registered to provide nursing care to up to 30 people who have a dementia type illness and 13 people who require general nursing care. The ground floor is designated for general nursing care, first floor to residents who have more advance stages of dementia and the top floor to residents who have less complex needs associated with their dementia. The home is owned by Barchester Healthcare Ltd. It is located next door to another nursing home owned by the same organisation and is close to the village of Burwash. Resident’s accommodation consists of forty-three single bedrooms with the provision to convert some to shared accommodation if requested. All bedrooms provide en-suite facilities. Shared space consists of communal kitchenettes, lounges and dining rooms on each floor. The home is set in its own grounds with panoramic views over the nearby countryside. The homes literature states That the aim of the home is to provide a happy, caring, comfortable home from home environment for the service users. The fees for residential care are currently range from £850 to £1,100 per week, depending on the services and facilities provided. Extras such as a community fee of £3,000 are charged prior to admission, newspapers, hairdressing, chiropody, toiletries are also additional costs. Dudwell St Mary New Building DS0000067584.V339044.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Care Standards Act 2000 and the Care Homes Regulations 2001 use the term service user to describe those living in care home settings. However for the purposes of this report those living at the home will be referred to as residents. This was a key inspection that included an unannounced visit to the home on the 27th June 2007 and included follow up contact with resident’s representatives and visiting health and social care professionals. There were 42 residents living in the home, six of whom were case tracked and also spoken with. During the tour of the premises ten other residents both male and female were also spoken with. The purpose of the inspection was to check that the requirements of previous inspections had been met and inspect all other key standards. A tour of the premises was undertaken and a range of documentation was viewed including the Service Users Guide, Statement of Purpose, care plans, medication records and recruitment files. Four members of care staff, two trained nurses and the chef were spoken with in addition to discussion with the clinical matron. The Annual Quality Assurance assessment (AQAA) was received back from the manager completed in full. Surveys received from ten residents and relatives were positive and indicated that both groups were satisfied with the services provided. One comment card was received from social and healthcare professional. The Inspectors would like to thank the residents, staff and management for their assistance and hospitality during the visit. What the service does well: The comprehensive Statement of Purpose and Service Users Guide gives prospective residents and relatives the information required enabling them to make an informed choice about where they live. Dudwell St Mary has been specifically designed to provide a spacious, wellequipped and comfortable home for the residents. The residents are encouraged and supported to bring in their own small pieces of furniture and personalise their rooms. The pre-admission assessments performed prior to admission ensure that the home can meet the identified needs and the family are involved as much as possible. Systems are in place to regularly consult with residents via service users meetings and surveys. There is an open-house policy, which welcomes visitors at all reasonable times. Returned surveys all confirmed that they were visited Dudwell St Mary New Building DS0000067584.V339044.R01.S.doc Version 5.2 Page 6 by the matron and/or manager prior to admission to the home and also invited to visit the home to see if they liked it enough to live there. ‘I was shown over the premises, including the bedroom and was able to ask questions’ ‘ Apart from brochures, we also came for a personal tour of the home, were able to ask various questions. The matron also visited us at home’. Robust recruitment practices are followed when selecting staff to work in the home. The facilities for mental stimulation and orientation are well thought out and appropriate to the needs of the residents. There is a varied and nutritious menu devised which allows residents a choice. Drinks and snacks are available at any time. The atmosphere of the home is pleasant with good interaction seen between residents and staff. The Comments received from residents and families regarding the care received included: ‘ Staff efficient, courteous and kindly’ ‘ there has to be a bit of give and take on both sides’ ‘ a Drs visit can always be arranged either at the surgery or in the home. Nursing care is always available’ ‘wonderfully kind staff’. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Dudwell St Mary New Building DS0000067584.V339044.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Dudwell St Mary New Building DS0000067584.V339044.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4 and 5. People who use this service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Information about the services offered at Dudwell St Mary II is available for all prospective residents and their families. Pre admission assessments are completed to ensure the home can meet the needs of prospective residents, and they are encouraged to visit the home. EVIDENCE: The Statement of Purpose and Service Users Guide have been recently been reviewed and updated. They are written in plain English and contain the information required for prospective residents and relatives to make an informed choice as to whether the home can meet their needs and expectations. All residents are provided with a copy- this was evidenced during the tour of the building and copies are available in the main reception area of the home. It was confirmed by viewing three contracts that the contracts and terms and conditions of residency have been reviewed and are clear and transparent. Dudwell St Mary New Building DS0000067584.V339044.R01.S.doc Version 5.2 Page 9 A review of the care documentation confirmed that pre-admission assessments are completed, and are currently completed by the matron and or a senior nurse. Five of the six assessments were found to be completed in full and were used to ensure new admissions to the home were suitable and that the home have the staff and environment to meet the care needs of the new resident. One resident’s admission to the frail elderly unit was not seen to be within the criteria for that specific unit. The information contained in these assessments is then used to provide the basis of the care documentation in the home. The prospective residents’ are seen either in their home or hospital before admission and it was confirmed that wherever possible the family or representative is involved. Two relatives confirmed that they were consulted about the pre-admission visit and were given the opportunity to attend. A recommendation of good practice is to document the venue and who was present at the assessment as part of the process to gain relevant information. The staff spoken with were aware of the registration categories of the home and feel confident that they have the necessary skills and training to meet those of the residents living in the home. One member of staff spoke positively of the training he has received since working at the home. The home is committed to improving the outcomes for residents suffering from a dementiatype illness and those with complex nursing needs. The home does not provide intermediate care. Dudwell St Mary New Building DS0000067584.V339044.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. People who use this service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Not all care plans and risk assessments provided up to date and pertinent information and guidance for staff on the individual residents assessed needs. The residents are treated with respect and dignity by the staff in all aspects of their lives. EVIDENCE: The care documentation pertaining to six residents were reviewed in depth as part of the inspection process. These were found to include plans of care, nutritional assessments, personal histories and risk assessments. On the whole the care documentation demonstrated that the care was reviewed and evaluated, however it was noted that the plans of care did not always accurately reflect all the care needs of residents. The care plans on the frail elderly unit were found to be in need of review and updating in respect of Dudwell St Mary New Building DS0000067584.V339044.R01.S.doc Version 5.2 Page 11 nutritional needs, moving and handling and wound care. The shortfalls were discussed and acknowledged during the inspection. The care plans for the residents suffering from a dementia type illness are not yet person centred and do not all reflect the mental and social care needs of the residents. A new care planning format specifically for residents suffering from dementia is due to be introduced in the near future which the matron is sure will address the shortfalls. Risk assessments for health needs are included in the care planning format used by the home, however not all risk assessments were found to be correctly completed and did not follow through with an appropriate plan of action when identified as required. Fluid charts for those that are at risk from dehydration are in place but are not completed between the hours of 8 pm and 8 am, thus not given a correct fluid balance over 24 hour period. Staff spoken with confirmed that they received a full report on each resident daily and read the care documentation that is kept in the main nurses station. They felt that their views were taken into account when planning resident’s care. Relatives and residents spoken with were very satisfied with the care provided at the home one saying that the home ‘should be commended for its care’ ‘my relative receives excellent nursing care and care workers are kind, considerate and supportive of her every need’ ‘Staff are efficient, courteous and kindly’. Residents spoken to were also very satisfied, comments included ‘they look after me very well’ ‘I feel very lucky living here’ ‘ I like it here’. A relative contacted the CSCI by telephone to convey her thoughts. ‘ Fantastic staff, the change in my relative since living in Dudwell St Mary is incredible, they are so kind and look after him very well’. Two purpose built clinical rooms were seen and were found clean, tidy and well stocked. The systems for recording and checking controlled drugs were found to be thorough. Medication Administration Charts were found to be competently completed in the main, however staff are not completing the back of the Medication Administration Charts (MAR) when residents refuse or do not take their prescribed medication. Also they need to remember to sign and date when stopping medication. Covert medication administration needs to be identified in the care plan, appropriately risk assessed and discussed within a multi disciplinary approach and reviewed on a regular basis. These areas were discussed with the senior nurses on duty during the inspection. Staff were seen to be respectful and considerate to all residents and visitors. Each of the residents were addressed by their preferred term and dressed appropriately in well-laundered clothing. ‘We always receive good communication- are shown compassion and understanding in facing the illness my mother has’. Dudwell St Mary New Building DS0000067584.V339044.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. People who use this service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Meals remain good in respect of both quality and variety that meets the majority of residents’ tastes and choice, however there is little documental evidence to support that the lifestyle experienced by residents at this time matches their expectations, choice or preferences. EVIDENCE: A programme of group and individual activities has been developed for the residents at the home, and this includes visiting entertainers, weekly exercise classes and occasional trips out on the newly acquired minibus. It was noted from viewing the activities programme that up to three days a week the planned activity is aromatherapy, communion and hairdressing, however those are obviously only for certain residents that have booked and other activities such as skittles, gardening and quizzes take place. The programme would be more interesting to residents if these sessions were advertised alongside the more insular activities. The activities co-ordinator was able to verbally demonstrate her knowledge of the residents and spoke of her aspirations for the activities in the home. She Dudwell St Mary New Building DS0000067584.V339044.R01.S.doc Version 5.2 Page 13 has identified suitable activities and occupation for both small groups and for individuals. It was acknowledged that she is not up to date with all the recording; some of the care plan documents had not been completed in a month. This gave the impression that only certain residents were receiving one to one sessions and participating in activity sessions. It would be beneficial if staff also were involved especially in the one to one sessions and staffing levels increased to enable all residents the opportunity to participate. The staff in the home could also support the activity co-ordinator by documenting the time they spend interacting positively with the residents, such as visiting the garden, and preparing a cup of tea. The documentation in care plans needs to improve to demonstrate how their social needs and mental health needs are met and to guide all staff. The new care plans will address some areas in need of improvement. Feedback from a survey received ‘ provide many options for activities, music etc’. Residents said that they are able to choose what they want to do and take part in activities if they wish. The lounge areas contain music centres with a variety of well known songs, books and cassettes are also readily available to the residents. The corridors are used as sensory awareness tools, with textured pictures and interesting memorabilia in the form of clothing and shoes. The lounge areas lead in to safe balconies with tables and chairs, which are used under supervision and there are plants and pots that residents care for. There is also a walled garden with a fountain, which is accessible to all residents. Visitors are welcome at any time, those spoken with said they feel comfortable visiting their relatives and friends, they are sure ‘they are well looked after’, and feel that they can talk to the staff if they want to know anything or have any concerns. One relative commented ‘the staff are very friendly and welcoming always greet us with a smile and an offer of a drink’. The staff said residents are encouraged make choices about all aspects of their day to day lives, and a number of residents said they are able to choose how they spend their time, in their own room or in one of the lounges, and the staff are there to help them if they need it. The meals viewed were found to be well presented with an emphasis on home cooking and fresh ingredients. Residents were able to have their meals where they wanted to and to have extra portions if they desired. Most residents and visitors praised the food, and the vegetarians in the home were well catered for. Menus are displayed in the dining areas and evidenced a varied and well balanced diet with choices available. There are kitchenettes on each of the units, which ensures the food is hot and that the residents can choose again from the choices. Staff serve the food individually after asking the resident how much they want, they can have seconds if they want. The dining areas are pleasantly furnished and decorated, providing residents with a relaxing and positive environment to eat their meals. Staff were observed assisting residents in a respectful manner and maintaining their dignity. Dudwell St Mary New Building DS0000067584.V339044.R01.S.doc Version 5.2 Page 14 Residents spoken with said that the food is very good, they can have something to eat any time they like, and their relatives and friends can stay for meals if they wish. Relatives are encouraged to help themselves to tea and coffee from the kitchenettes. The home were inspected by the Environmental Health Agency in February 2006. Dudwell St Mary New Building DS0000067584.V339044.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. People who use this service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The complaint procedure is clearly detailed in the Statement of Purpose and Services Users Guide and is available to residents and their families enabling them to share their concerns formally and confidentially. Staff interviewed had a good understanding and knowledge of Adult Protection policies and procedures, which protect the residents from harm and abuse. EVIDENCE: The complaint and compliment file was seen. The complaints recorded showed that senior staff follow the company procedures for dealing with complaints. There are appropriate policies and procedures in place regarding complaints, and it was confirmed that these are followed when investigating any concerns raised at Dudwell St Mary. The complaint book was viewed and this demonstrated that all complaints are recorded, along with the outcome and action taken by the home to resolve the complaint. The staff interviewed were knowledgeable regarding the complaint procedure and of how to start the process if the manager is not available. No complaints have been received by the CSCI since the last inspection. Four of the ten surveys received stated that they were aware of the complaint procedure and would have no problem with raising a concern if they wanted to. Dudwell St Mary New Building DS0000067584.V339044.R01.S.doc Version 5.2 Page 16 The Adult Protection policy in the home was found to be up to date and staff interviewed were knowledgeable about the systems in place to protect vulnerable service users. There is on-going training for all staff in Protection of Vulnerable Adults. Dudwell St Mary New Building DS0000067584.V339044.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 23, 24, 25 and 26. People who use this service experience excellent quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home provides a comfortable, clean and safe environment for those living there and visiting. Residents are enabled and encouraged to personalise their bedroom, and rooms are furnished and decorated to a high standard yet remain homely and reflect the resident’s personalities and interests. There is specialist equipment in the home for residents’ use to maximise their independence. EVIDENCE: The home was purpose built to provide a safe, comfortable and homely environment for residents with nursing needs and for those suffering from a dementia type illness. The home has the necessary adaptations and aids to enable and promote independence. The home operates a door key system to Dudwell St Mary New Building DS0000067584.V339044.R01.S.doc Version 5.2 Page 18 each floor, which ensures the residents safety when wandering and also ensures that staff are aware of whom is in the building. The home is decorated and furnished to a high standard. The relatives were very complimentary regarding the homes décor and maintenance. ‘Its so spacious and light’ ‘ a beautiful building that really makes it a home’. A great deal of thought has gone in to the décor and fixture and fittings of the home. Each floor is individual and has followed themes to encourage recognition and interest. There are textile pictures for residents to touch and one floor has a range of evening shoes and boas, whilst another has old sewing machines and a dress making bust. The communal space consists of a combined lounge dining room and kitchenette on each of the three floors. There are well maintained grounds in which there are pathways and various patios with eating areas. There is a balcony on the first floor, which residents can access independently and tend to pots of flowers. The balcony also has high Perspex clear walls to protect residents from cold winds, so they can continue to enjoy the fresh air. Residents that live on the top floor are supported by staff to access the walled, well maintained gardens. One resident said ‘ the gardens are so pretty and change according to the season, like an ever changing picture’. All bedrooms have an ensuite shower room and there are a sufficient number of separate toilets and bathrooms located around the home. There is a range of individual aids and adaptations to assist resident’s mobility and independence, this includes raised toilet seats, walking aids, hoist ramps, automatic doors, and grab rails. A range of different style assisted baths are available for residents differing needs. There is resident call system in the home and call points are fitted throughout the home that enables assistance to be summoned. The residents in the dining areas and lounge areas did not have access to a call bell, those residents that can’t physically ring for help, need to have an appropriate risk assessment in place and a plan of action/monitoring to ensure their safety and comfort. From direct observation on the day of inspection all calls were answered promptly. Resident’s bedrooms are well furnished with high profile nursing beds and aids to enable them to be as independent as possible. Residents and their families are encouraged to personalise their rooms and also bring in small bits of furniture. One resident said that that she had brought in her favourite small pieces of furniture. Polices and procedures for infection control are in place and are updated regularly. The home was clean and free from offensive odours on the day of the inspection. It was again noted that staff are not following the home’s procedures in the use of gloves; this is to be reinforced to staff. All sluices were found in good working order and clean. Dudwell St Mary New Building DS0000067584.V339044.R01.S.doc Version 5.2 Page 19 The laundry area was clean and well organised and the standard of the laundry was seen to be good. One comment received was that woollens are tumble dried too much and become creased. Dudwell St Mary New Building DS0000067584.V339044.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. People who use this service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents are protected by the home’s recruitment policy and practices, however staffing levels need to be flexible and dependant on the documented needs of the residents. EVIDENCE: The staffing rota was viewed and the staffing levels were seen to be insufficient to meet the needs of the residents on the day of the inspection, in particular on the frail nursing floor. It was stated by the manager that this was due to the recent resignation of two members of staff and is not normal. Recruitment of new staff has taken place. The first floor were one staff member down all morning until an agency staff arrived at midday. The staff coped well and remained cheerful and attentive to the residents needs. The staffing levels must be kept under constant review to reflect any increased activity level in the home and be based on the dependency of residents. Residents stated that they had no real complaints regarding the amount of staff, but one resident said the ‘staff are always helpful, they look after me Dudwell St Mary New Building DS0000067584.V339044.R01.S.doc Version 5.2 Page 21 very well, but I know they are short of time sometimes’. Another said, ‘ The staff are really nice, very kind and look after me very well’. Robust procedures are followed when employing staff. They contain the required information and demonstrate that the appropriate induction training had been undertaken in respect of the job they were to undertake in the home. One member of staff that had recently been employed said ‘ I have had a very good induction and orientation to the home’. Staff interviewed confirmed a satisfaction with the training provided and stated that recent training was interesting and informative. Compulsory training such as moving and handling, adult protection, first aid, and food hygiene and fire safety are all being undertaken. Mandatory training will be on-going and organised by the Organisation. In addition specialist training in understanding dementia, supra pubic catheterisation, updates are also provided. NVQ training is available and staff are encouraged to complete this, at present only 10 of staff have an NVQ qualification, but the matron confirmed further staff are enrolling. It was a concern that the trained nurses and carers that care for the residents with a dementia type illness have not all received training in understanding dementia. This was discussed and the staff are all due to receive training in the near future. Dudwell St Mary New Building DS0000067584.V339044.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 34, 35, 36, 37 and 38. People who use this service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The management approach at Dudwell ST Mary II is open and encourages residents, relatives and staff to be actively involved in decisions about the services provided at the home. The health and safety of residents is protected through an ongoing training programme for staff. EVIDENCE: The newly appointed manager has been in post since 01 June 2007. He has been working in the home for some time specifically being involved in prospective residents placements. Residents already know him well and were very pleased with his appointment. He has experience in general management and is enrolled on a management qualification. He is not a registered nurse, Dudwell St Mary New Building DS0000067584.V339044.R01.S.doc Version 5.2 Page 23 but will be fully supported by a clinical lead matron. Their working relationship and communication was seen as open and positive. Residents, relatives and staff are encouraged to participate in discussions about the services provided at the home. The manager confirmed that feedback is sought from all groups and individuals who have any contact with the home, as part of the quality assurance system, and monitoring of all aspects of the care and support provided is carried out on a regular basis. The formal quality assurance and quality monitoring systems enable the management to objectively evaluate the service and ensure it is run in resident’s best interests. Questionnaires are made freely available and sent directly to head office where the results are analysed. Relative and resident meetings are planned to commence monthly in July. Residents are encouraged to retain control of their own finances for as long as they are able to do so and if unable then this responsibility is taken on by a relative or another responsible persons external to the home. Residents are safeguarded by the robust accounting and financial procedures in the home. Staff spoken with said they felt well supported from their colleagues but did not have regular supervision with their manager. The manager reported that yearly appraisals are undertaken but regular supervision has not yet been fully implemented for all staff. It is planned that supervision will be delegated out to different levels of staff. Records were available to demonstrate that fire alarms, water temperatures and emergency lighting systems are regularly tested and fire drills undertaken. Testing of portable electrical appliances has been carried out. Certificates to demonstrate that bath hoists, gas appliances, electrical systems and appliances are safe re confirmed as being in place. Policies and procedures are available in relation to health and safety and good practice was evident in the management of records relating to accidents, servicing and repair of equipment. Training required by legislation, including moving and handling, fire training and infection control is being provided for all staff to protect the health and safety of residents. Those that are not up to date are being appropriately supervised to ensure the safety and well being of the residents. Dudwell St Mary New Building DS0000067584.V339044.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 3 3 X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 4 4 4 4 4 4 3 3 STAFFING Standard No Score 27 2 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X 3 2 3 3 Dudwell St Mary New Building DS0000067584.V339044.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP7 Regulation 15(1)(2) 12 Requirement That care plans provide clear guidance for staff on all aspects of the health, personal and social care needs of service users and which make explicit the actions needed to meet these needs and which are reviewed regularly. (Timescale of 30/03/07 not met) Timescale for action 30/09/07 2. OP8 13(1b) 17(1a) Sch3 That health related risk 30/09/07 assessments are accurate and up dated regularly to reflect the residents identified needs. In particular fluid charts, wound assessments and moving and handling assessments. 30/09/07 That a care plan is in place with an appropriate risk assessment for covert administration of the specific service users medication. With evidence of a multidisciplinary discussion with health professionals and family. That the recording of refused medication is correctly recorded on the medication administration Charts. 3. OP9 16 (2) Dudwell St Mary New Building DS0000067584.V339044.R01.S.doc Version 5.2 Page 26 4. OP12 16(2m) 23(2h) 12(4b) 18(1)(a) 5. OP27 That the staff all That all service users are consulted about the programme and range of activities and are enabled to attend the activities on a regular basis. That there are sufficient staff on duty at all times to meet the needs of the service users. That persons working at the home are appropriately supervised. (Timescale of 30/01/07 not met) 30/09/07 30/09/07 6. OP36 18(2) 30/09/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Dudwell St Mary New Building DS0000067584.V339044.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Maidstone Local Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Dudwell St Mary New Building DS0000067584.V339044.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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